1. Confined Spaces— The Case of the Invisible Gas
P O W E R P O I N T ® T R A I N I N G
Target Audience: This session is most appropriate for workers that are trained as confined space entrants, attendants, and rescuers. The session would also be appropriate as precautionary training for any worker who has confined work spaces in their workplace, even if they do not regularly have reason to enter the confined spaces. This session is probably not appropriate for workers with no confined spaces in their workplace.
Learning Objectives: This case and its training message primarily have to do with confined space entry and the hazards of hidden gases. It can be used as part of a complete confined space training session, or it can be used as refresher training.
Background for the Trainer:
This training session presents a case study of an actual accident, which was inspected and documented by the Occupational Safety and Health Administration (OSHA). The case presented in this training session is:
Accident:
Report ID:
Inspection:
You may choose to present this training information in a lecture format, or make the training presentation interactive by engaging your class in discussions that will help them identify facts of the case, potential causes of the accident, and future accident prevention measures. In either case, students will benefit by learning from a real-life scenario.
Before beginning your training session, print and make copies of the one-page Case Study Student Handout, which is provided on the disc. The Case Study Student Handout can be used as a worksheet during the training session or as a take-away reminder once the training session is complete.
Also, print and make copies of the Case Study Quiz, which is provided on the disc as a fully customizable Word document. The students can take the quiz at the end of the training session in order to help reinforce the information presented. Note that the same quiz is included at the end of this PowerPoint presentation as actual slides to review in class.
Consider taking pictures of workers entering confined spaces in your workplace. You can add these pictures to the presentation by inserting them into existing slides or creating new slides.
Make sure the trainees understand the message as you go along. Ask questions periodically to test their understanding.
Speaker’s Notes:
Welcome everyone. Today we will conduct a case study of an actual accident, which was investigated by the Occupational Safety and Health Administration (OSHA). This is an actual tragic workplace accident that had real-life implications for the worker, the worker’s family, co-workers, and the employer. The Case Study may be disturbing and may even involve a fatality.
The purpose of this training session is to teach and reinforce the importance of following confined space entry procedures in your workplace in order to prevent tragic accidents. In particular, it deals with how to check the confined space for potential hazards. The intention is to learn from the accident and take steps to prevent a similar accident from changing our lives.
Confined Spaces—
The Case of the Invisible Gas

2. Let’s Talk About Confined Spaces
Each year there are about 20 fatalities related to working in confined spaces.
More than 1,000 serious injuries occur each year requiring days away from work.
Background for the Trainer:
Bring your company’s written Confined Space Entry Plan and Procedures for employees to review or discuss.
Speaker’s Notes:
Each year there are about 20 fatalities related to working in confined spaces.
More than 1,000 serious injuries occur each year requiring days away from work.
OSHA defines a confined space as any space that meets all three of the following criteria:
The space is of a size and configuration sufficient for a person to enter and perform work. Access might be obtained through a number of means, such as doors, hatches, manholes, access panels, ladders, etc.
The space has limited or restricted means for entry and exit. Not all confined spaces have restricted means of entry or exit. Pits, tanks, or vats can have open tops, which means entry is not restricted; however, entry and exit are limited because a ladder or other special equipment is required to enter the space.
The space is not designed or intended for continuous human occupancy. Examples of confined spaces include: tanks, vessels, silos, storage bins, hoppers, vaults, pits, boilers, furnaces, sewers, and utility tunnels.

3. What is a Confined Space?
A confined space is large enough to enter
Has a restricted means of entry/exit
Is not intended for continuous human occupancy
Examples include: tanks, vessels, silos, storage bins, hoppers, vaults, pits, boilers, furnaces, sewers, and utility tunnels.
OSHA defines a confined space as any space that meets all three of the following criteria:
The space is of a size and configuration sufficient for a person to enter and perform work. Access might be obtained through a number of means, such as doors, hatches, manholes, access panels, ladders, etc.
The space has limited or restricted means for entry and exit. Not all confined spaces have restricted means of entry or exit. Pits, tanks, or vats can have open tops, which means entry is not restricted; however, entry and exit are limited because a ladder or other special equipment is required to enter the space.
The space is not designed or intended for continuous human occupancy. Examples of confined spaces include: tanks, vessels, silos, storage bins, hoppers, vaults, pits, boilers, furnaces, sewers, and utility tunnels.

4. Take a Look at the Facts
Two employees arrive at concrete pit at demolition site
Employees experience a burning sensation in eyes when pit is uncovered
Background for the Trainer:
Training Option: Pass out the Case Study Student Handout. You may have the students read the accident description to themselves before discussing it in the class, or you may use the bullet points on the slide and the speaker’s notes below to describe the accident.
Speaker’s Notes:
The employees arrive at the demolition site where they have been working to salvage the bottom part of a cardboard baler imbedded in a concrete pit.
When the employees uncover the pit, they both feel a burning sensation in their eyes.

5. Take a Look at the Facts (cont.)
Employee #1 descends into pit to investigate
Employee #1 climbs out, saying the pit is hot
Speaker’s Notes:
Employee #1 climbs down into the pit to determine what might be causing their eyes to burn.
Employee #1 climbs out of the pit because it is hot. He wants to put a water hose into the pit to help cool it down.
© Business & Legal Reports, Inc. 0908

6. Take a Look at the Facts (cont.)
Both employees enter pit with a water hose
Both have difficulty breathing and burning eyes
Employee #2 retreats and Employee #1 collapses into the pit, unconscious
Speaker’s Notes:
Both employees climb down into the pit with the water hose.
Both employees experience chest tightness, difficulty breathing, and burning eyes.
The employees decide to exit the pit because of the intolerable conditions. Employee #2 climbs out first.
As Employee #1 is climbing the ladder to get out, he is overcome by the fumes and falls back into the pit. He lands on his back, unconscious.
© Business & Legal Reports, Inc. 0908

7. Take a Look at the Facts (cont.)
Employee #2 is unable to get Employee #1 out of the pit
There was a fire in the pit the day before
Smoldering fire created a buildup of carbon monoxide
CARBON MONOXIDE
BUILDUP
Speaker’s Notes:
The employees decide to exit the pit because of the intolerable conditions. Employee #2 climbs out first.
Employee #2 climbs down into the pit in an attempt to rescue employee #1, but is unable to lift him. Employee #2 exits the pit in order to get help.
During the investigation, it was discovered that employee #1 had attempted to extinguish a small cutting torch fire the day before by covering it with sand and dirt.
Apparently the fire was not extinguished and smoldered overnight, which resulted in a build up of carbon monoxide inside the pit.
© Business & Legal Reports, Inc. 0908

8. What Do You Think Went Wrong?
What are the hazards of confined spaces?
Were these workers properly trained to enter confined spaces?
What type of air monitoring should be done before entering a confined space?
Was this a permit-required confined space?
Was confined space rescue equipment readily accessible?
Background for the Trainer:
Use the questions on this slide to elicit discussion.
Training options: After reviewing this slide and the accident description, give the class 5 to 10 minutes to discuss the accident description in small groups; or ask the students to try to determine some of the facts, potential causes, and possible prevention measures. In either case, use the Case Study Student Handout to encourage discussion as you go through this presentation.
Speaker’s Notes:
Let’s take a few minutes and, using the Case Study Student Handout, work in groups to try to determine the facts of the accident, potential causes of the accident, and possible prevention measures. Then we will review the Case Study together in class.
Consider some of the questions on this slide when discussing the Case Study in your groups.

9. Let’s Review the Causes
Employees not following documented guidelines for entering confined spaces
Their actions represent a possible lack of training
The employees ignored “red flags”
No indication of permit for confined space entry
Air not monitored for safety
Rescue equipment or procedures were not utilized
Background for the Trainer:
Try to get the trainees to put themselves in the place of the person in the case study. What would they have done in this case? Point out how a near miss can turn into a catastrophe in the presence of emergencies. In this case, the workers probably were unaware of confined space hazards and just wanted to get into the pit and get their job done so they ignored the warning sign of the burning eye sensation. What would have been a near miss if both employees had heeded the warning sign and stayed out of the tank instead cost a worker his life.
Speaker’s Notes:
Employers that have confined spaces on-site or require employees to enter confined spaces must have a written Confined Space Entry Plan and Procedures . This written program will include: identification and marking of all confined spaces, hazards of confined spaces, atmosphere monitoring procedures, ventilation plans, entrant and attendant training and responsibilities, rescue plans, safe work practices for jobs done in confined spaces, procedures for completing confined space permits, list of equipment needed to enter confined spaces, specific hazards and entry procedures for each confined space, etc.
There is no indication on the accident report that the employees were trained as authorized entrants of confined spaces. If they did receive any confined space entry training, they did not apply any of the training. Authorized entrants are trained on the hazards of confined spaces, air testing procedures, symptoms of lack of oxygen or exposure to toxic chemicals, personal protective equipment (PPE), communication equipment, rescue retrieval equipment, etc.
These employees entered the space despite experiencing “red flags,” such burning eyes. An important part of training for confined space workers includes learning the signs and symptoms of a lack of oxygen or exposure to toxic chemicals. Workers should never enter a space, and should immediately leave a space, in which they experience symptoms of lack of oxygen or overexposure to toxic chemicals.
Most confined spaces require a permit before workers can enter the space. Permit-required confined spaces have the potential for hazards such as: hazardous atmospheres, engulfment, entrapment, falls, heat, combustibility, etc. By completing a permit, entrants know they have obtained all the necessary equipment and the atmosphere has been monitored so they know the space is safe to enter.
This worker died of asphyxiation, or lack of oxygen. If the pit had been monitored prior to entry, this accident would not have occurred. Common monitoring practices require a check of the oxygen concentration, a check for flammable gases or vapors (especially important if welding is going to be done in the space), and finally, a check for any other toxic chemicals known to potentially be in the space. Monitoring is conducted before entering the space and periodically while workers are in the space.
The worker that collapsed back into the pit while climbing out could not be rescued because he was not wearing required rescue equipment. He should have been wearing a full-body harness attached to a retrieval line that was connected to a winch-type system that could have been used to pull the unconscious worker out of the pit. Of course, the other employee would have had to have been trained in confined space rescue procedures.
Can you think of any other causes that may have contributed to this accident?

10. Confined Space Permits
Clearly identify the space to be used and is posted just outside the entrance.
Permit information includes:
Date, purpose, and duration
Authorized entrants, attendants, and entry supervisor
List the hazards of the space
Atmospheric, entrapment and engulfment potential, fall hazards, etc.
Background for the Trainer:
Bring copies of your company’s Confined Space Permits for employees to review and discuss.
Speaker’s Notes:
The confined space permit will identify the specific space that is being entered. The permit must be posted just outside the entrance to the space for all authorized entrants and attendants to review.
The permit will include the date, purpose of entry (i.e., specific work being done), and the authorized length of entry. If the work takes longer than expected, a new permit must be completed.
The permit will also list all authorized entrants, attendants, and the entry supervisor. The attendant will keep track of which authorized entrants are in the space at all times.
The permit will also discuss the hazards of the space, including: atmospheric hazards, entrapment potential, engulfment potential, fall hazards, heat or noise hazards, lockout/tagout procedures that need to be performed, hot work permits for welding in the space, etc.

11. Confined Space Permits
Air monitoring results are posted and monitoring is performed periodically if the space has potential for hazardous atmospheres
The permit lists equipment to use in the space such as PPE, ladders, lighting, non-sparking tools, etc.
Rescue services and procedures, identifying the instructions for calling the trained confined rescue team are included on the permit
The permit will also show the results of the air monitoring that was conducted so authorized entrants can be assured that the space is safe. If monitoring shows lack of oxygen or a high concentration of flammable vapors or toxic chemicals, then the permit will discuss what is being done to improve the atmosphere of the space—such as ventilation. In some cases, workers may be required to enter a space even with hazardous atmospheres, but the permit will tell them what type of respiratory equipment and PPE is needed.
The permit will list the equipment that is needed to enter the space, such as: PPE, ladders, lighting, nonsparking tools, ventilation equipment, fire extinguishers, rescue harnesses and retrieval equipment, communication devices, personal air monitoring equipment, etc.
The permit will describe rescue procedures as well as how to call the trained confined space rescue team.

12. Confined Space Rescue
Never attempt a rescue unless part of a trained team
Wear full-body harness when entering a space
Keep the retrieval line attached to your harness
Background for the Trainer:
Bring any written procedures your company has for confined space rescue.
Show pictures of your employees conducting a confined space rescue drill.
Speaker’s Notes:
Never attempt to rescue a co-worker unless you are part of a trained rescue team. Employee #2 in this accident was very lucky that he was not overcome by the lack of oxygen in the pit—he could easily have been seriously injured as well. Even if you are a trained rescuer, do not attempt the rescue until others from your team have arrived. Always attempt to perform the rescue from outside the space by using a winch or other means to pull the worker out. If you have to enter the space, never rush into the space – make sure you are wearing all the appropriate PPE.
Help facilitate your own rescue from a space by always wearing appropriate rescue gear, such as a full-body harness. You will be pulled out of a hazardous situation much faster, and your chances of survival will be much greater.
Keep the retrieval line attached to your harness at all times. Disconnecting the harness because you feel entangled or uncomfortable is not a safe procedure.

13. Confined Space Rescue (cont.)
Inform the rescue team that a space is being entered
Conduct rescue drills in actual confined spaces
Speaker’s Notes:
Inform the rescue team that a space is being entered. Make sure all rescue team employees are aware that you are entering a confined space and they should be ready and available if called upon. Rescuers must be able to respond quickly to a confined space emergency.
Rescuers must conduct regular drills in actual confined spaces in the workplace. Rescuers will not be adequately prepared if they receive classroom training only. They must conduct drills in the confined spaces that they may actually have to rescue a victim from. Contracted rescuers must have access to the confined spaces in your facility so they can conduct regular rescue drills.
© Business & Legal Reports, Inc. 0908

14. Don’t Let It Happen to You
Never enter a confined space unless you are trained
Make sure the permit is complete before entering
Know the hazards of the confined space
Monitor the atmosphere before entering
Wear proper PPE and rescue equipment
Leave the space if you notice any symptoms
Speaker’s Notes:
Let’s take a look at what we can do to prevent a similar incident from happening at our facility.
Never enter a confined space unless you are a trained entrant. Know how to recognize confined spaces and avoid them.
If you are a trained confined space entrant, make sure the permit is complete and signed off by the entry supervisor before entering the space. When the permit is approved it means the space is safe to enter. The air has been monitored and all necessary work, safety, and rescue equipment has been obtained.
Know the hazards of the space before you enter it. What are the atmospheric hazards and symptoms of exposure to those hazards? Is there potential for engulfment? Are all energy sources locked out properly? Are the floors of the space sloped so that you might fall into a small space and become trapped? Are fall hazards present?
Monitor the atmosphere. Oxygen must be between 19.5% and 23.5% to be safe. The concentration of flammable vapors must be less than 10% of the chemical’s lower flammable limit (LFL). The concentration of specific toxic chemicals in the space must be below the chemical’s permissible exposure limit. If monitoring shows the atmosphere is not within these limits, the space must be ventilated or entered with special equipment, such as air-supplied respirators.
Wear the appropriate PPE and rescue equipment for the space. Respirators, gloves, hard hat, clothing, boots, and safety glasses are examples of PPE. A full-body harness attached to a winch is an example of rescue equipment.
Learn to recognize symptoms of exposure to toxic chemicals that might be in the space or symptoms of a lack of oxygen. Leave the space immediately if you experience any of these symptoms. The attendant is also watching entrants for signs of overexposure and will order an evacuation if an entrant appears to be experiencing symptoms.
Are there any questions?
Thanks for your attention.

15. Mangan’s Requirements
Read and follow the client’s procedure for entering a confined space
Review Mangan’s Policy for Confined Space entry located on the ADP Portal
Notify Mangan’s Safety Department for specific training prior to entering a Permit Required Confined Space